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Generator, Maii g copy to - U TSO P.O. Box 400 Sacramento, Caa. 95812-44GO within 30 rays. n '� <br />Please print or type. (Form designed for Use on elite (12 -pitch) typewriter.) Form Aooroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. rye%"Y DESIGNATED FACILITY TO GENERATOR <br />-1:MR <br />AL <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1.%C�nerajjtor II..D, Number { <br />7/ "�/ <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />0 0 8 6 4 <br />( j 000, z I <br />800_$244„9300 <br />5. Generator's Name and Mailing Address ---r' Generator's Site Address (if different than mailing address) <br />�/ �l NOV 04 2013 <br />X��f n <br />i. n�ratofs Phone: � r .� ��� �1 o C,� q � -z <br />6. Transporter 1Company Name U.S. EPA ID Number V�RONMEN <br />E ; uea� r Eil onmentai Services C.AD9 2- DF <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Evergreen Oil, Inc. <br />6830 Smith Ave. CA098088 418 <br />N£wai!,, Oa. fl4560 <br />Facility's Phone: �• r .,y, H„ �� 0 <br />9a. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />rr <br />r <br />1 ' I�, 'l %fly �i ��dq/7-% ----/, ���f <br />_ <br />,( <br />A /X <br />UJ <br />3.Safi.��1�"��A�&��,f'✓".�+ad'��.�", ��`�i11 <br />4. <br />l <br />144. Special Handling Instructions and Additional Information <br />5 71 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationafand national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if l am a small quantity generator) is true. <br />Gener4ges/Offeror's Printed/Typed Name' Signa Month Day Year <br />c' 1 -Q Hill 101 <br />F- <br />16. International Shipments J <br />Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed(T'yped Name Sign re M th Day Year <br />CL <br />QTransporter <br />2 Printedrryped Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />w <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/ryped Name Signature r Month Day Year <br />p <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. rye%"Y DESIGNATED FACILITY TO GENERATOR <br />-1:MR <br />AL <br />